切割吻合器在右半结肠切除术中的临床应用

为寻求一种右半结肠切除后快捷安全的消化道重建方式,回顾分析我院应用切割吻合器行消化道重建的43例右半结肠癌患者的住院治疗资料。结果显示,43例患者均顺利康复出院,平均手术时间76min。结果表明,切割吻合器在右半结肠切除术的消化道重建中应用具有明显优势,是一种快捷安全吻合且并发症少的手术方式。     

直线型切割吻合器在BillrothⅡ式胃大部切除中的应用体会

我院自1995年以来应用直线型切割吻合器行远端胃大部切除术后胃空肠侧侧吻合47例,疗效满意,现报告如下。临床资料本组47例中,男31例,女16例。年龄23～78岁,平均46.3岁。胃窦癌行远端胃大部切除26例,壶腹周围癌行胰十二指肠切除术胃空肠吻合21例。吻合器类型:所用吻合器为TCL55～77(55～77mm)型直线切割吻合器(均为强生公司产品)。吻合方法:(1)胃窦癌远端胃大部切除术后吻合:远端胃大部切除后,用闭合器(TL90,强生公司产品)或手缝闭合残胃断端。将残胃的大弯侧胃结肠韧带和脾胃韧带向上游离8cm左右,以便空肠在胃后壁与其进行侧侧吻合。距屈…     

直线切割吻合器在右半结肠切除术中的应用

我院2004年至2008年共对136例结肠肿瘤患者行右半结肠切除术直线切割吻合器侧侧吻合,不仅节省手术费用,且手术时间更短,降低了腹腔和切口感染率.现报告如下.     

腹腔镜前入路右半肝切除的临床应用

目的 探讨腹腔镜前入路右半肝切除术的临床应用价值.方法 回顾性分析2017年6月至2019年5月期间自贡市第四人民医院肝胆胰脾诊疗中心收治的32例行腹腔镜前入路右半肝切除术患者的临床资料.结果 32例腹腔镜前入路右半肝切除术均顺利完成,无中转开腹.手术时间(315.5±36.7)min,术中出血量(340.8±105....     

水媒射频切割闭合器在肝切除中的应用

目的总结水媒射频切割闭合器在肝切除中的应用。方法总结了12例应用水媒射频切割闭合器行肝切除的病人的资料，对其断肝的结果进行了分析。结果12例病人分别行不同类型的肝切除，术中断肝时间为30～130min，平均76min；出血量为20～300ml，平均85ml；术中术后均未输血。术后患者均无胆漏、腹腔内残余感染等并发症发生。有3例患者有术后一过性转氨酶升高，最高达550IU／L。切开手术标本检查见切缘凝固变性组织深度3～5mm。切缘肝组织经病理学检查发现从表面往内呈坏死区、变性坏死过渡区、充血水肿区和相对正常的移行改变。管道周围肝组织变性坏死程度较其它邻近区域明显，沿管道区呈放射状分布。结论应用水媒射频切割闭合器行肝切除是一种较满意的方法。     

弧形切割吻合器在低位直肠癌双吻合器技术中的应用

目的 评价弧形切割吻合器在双吻合器技术中的作用.方法 309例低位直肠癌患者分别采用弧形切割吻合器(弧形切割吻合器组,90例)及直线型闭合器(直线型闭合器组,219例)进行双吻合器吻合,对两组患者的术后保肛率及并发症进行比较.结果 弧形切割吻合器组保肛率(57.8%)高于直线型闭合器组(44.7%),两组比较,P＜0.05,差异有统计学意义.两组吻合口瘘、吻合口狭窄和吻合口出血发生率比较,P＞0.05,差异无统计学意义.结论 应用弧形切割吻合器可以提高低位直肠癌患者的保肛率.     

水媒射频切割闭合器在肝切除中的应用

目的总结水媒射频切割闭合器在肝切除中的应用。方法总结了12例应用水媒射频切割闭合器行肝切除的病人的资料,对其断肝的结果进行了分析。结果12例病人分别行不同类型的肝切除,术中断肝时间为30~130min,平均76min;出血量为20~300ml,平均85ml;术中术后均未输血。术后患者均无胆漏、腹腔内残余感染等并发症发生。有3例患者有术后一过性转氨酶升高,最高达550IU/L。切开手术标本检查见切缘凝固变性组织深度3~5mm。切缘肝组织经病理学检查发现从表面往内呈坏死区、变性坏死过渡区、充血水肿区和相对正常的移行改变。管道周围肝组织变性坏死程度较其它邻近区域明显,沿管道区呈放射状分布。结论应用水媒射频切割闭合器行肝切除是一种较满意的方法。     

一次性弧形切割吻合器在腹腔镜直肠癌前切除术中的应用

探索腹腔镜直肠癌前切除手术中远切端的离断新方法,以降低手术费用,为在经济欠发达地区推广该手术创造条件。观察组20例,术中取耻骨联合上方水平辅助切口,并以一次性弧形切割吻合器离断远切端,完成腹腔镜直肠癌前切除术。对照组20例,左侧经腹直肌辅助切口使用ETHILON直线切割吻合器离断远切端,完成腹腔镜直肠癌前切除术。观察2组患者辅助切口的长度、手术时间、术后并发症、肛门功能恢复情况、离断远切端的耗材费用、患者自我认定的恢复情况。观察组辅助切口的长度为(5.3±1.2)cm,对照组辅助切口的长度为(4.9±1.1)cm。观察组手术时间为(256±34)min,对照组手术时间(285±27)min。术中、术后无一例严重并发症发生,观察组和对照组吻合口狭窄的发生率为15%和10%,2组之间差异无统计学意义(P0.05)。2组均没有并发吻合口瘘。术后半年,2组肛门功能恢复均良好。观察组离断远切端的耗材费用为3 255元,对照组离断远切端的耗材费用6 436元(或8 998元,2个切割闭合器钉仓)。应用一次性弧形切割吻合器可以代替直线切割吻合器完成中、上段直肠癌,直乙交界部癌腹腔镜直肠癌前切除术,达到降低手术费用的目的,可在经济欠发达地区推广该手术。     

肝提拉技术在肝切除中的应用

在肝脏切除手术中,由于肝脏本身体积较大、且内部及周围存在众多的管道系统,深部术野显露困难,因此,术中易发生难以控制的大出血及下腔静脉损伤等严重并发症。Belghiti等于2001年首先报道了肝提拉技术（liver hanging maneuver,LHM）,利用肝后下腔静脉前面的间隙建立隧道并留置弹力带,在未游离肝脏情况下通过前入路成功实施右半肝切除,从而有效地保护了下腔静脉。彭淑牖等率先在国内开展这一技术,将其命名为“绕肝提拉法”,并对一些重要步骤进行改进,扩大了手术应用范畴。现在LHM已成为许多复杂肝脏手术的一种安全、可靠的技术方法。     

完全腹腔镜下右半肝切除

腔镜技术的发展已经在很大程度上改变了外科手术的方式，位于密闭体腔内的手术正越来越多地通过微小戳孔和应用腔镜来实施。腹腔镜外科技术已逐渐进入成熟阶段，并被用于腹腔大多数脏器的手术，但由于肝脏的体积特点、复杂的管道系统和丰富的血供特征，使得肝脏成为腹腔镜外科发展的最后阻力。这一世界性难题吸引了众多腹腔镜外科医师积极尝试。在早期文献中腹腔镜肝切除病例多属于外周肝段（S2～S6）、小病灶（直径〈5cm）的局限性切除。     

完全腹腔镜下右半肝切除术的体会

目的探讨完全腹腔镜下右半肝切除术的操作要点和注意事项。方法分析3例完全腹腔镜下右半肝切除术患者的临床资料、手术操作要点及治疗效果。结果 2例患者顺利完成完全腹腔镜下右半肝切除术,手术时间分别为130min和150min,术中出血量分别为200ml和450ml,术后住院时间均为5d。1例因术中血管瘤破裂出血而中转开腹,中转开腹前出血量约800ml。3例患者术后均顺利恢复,无出血、胆漏等相关并发症发生。结论合理选择患者、术中细致操作、果断中转开腹,完全腹腔镜下右半肝切除术是安全可行的。     

Laparoscopic right hepatectomy: a challenging, but feasible, safe and efficient procedure

Background

Few centers are undertaking major laparoscopic liver resections, because of the well-recognized technical difficulties and lack of training opportunities.

Methods

The authors describe their technique for laparoscopic right hepatectomy, highlighting relevant details for accomplishing a safe and efficient procedure. Patients were chronologically divided into 2 groups to evaluate the impact of increasing experience on the surgical outcomes.

Results

Group I included 17 patients and group II 18 patients. The conversion rate to open or hybrid techniques significantly decreased from 36% in group I to 6% in group II (P = .03). The hospital stay decreased from a median of 6 days in group I to a median of 4 days in group II (P = .05). Complications occurred in 4 patients (11%), of whom 3 were in group I. The mortality was zero.

Conclusions

Laparoscopic right hepatectomy is a safe and efficient procedure when performed at specialized centers with extensive experience in hepatic surgery. Long-term training is necessary to acquire adequate expertise.     

Laparoscopic versus open right hepatectomy: a comparative study

Background

The safety of laparoscopic major liver resections is still uncertain. The aim of this study was to compare our results for laparoscopic right hepatectomy (LRH) with those for open right hepatectomy (ORH).

Methods

Patients undergoing LRH were compared with retrospectively selected patients from our ORH database. The 2 groups were well matched for sex, age, American Society of Anesthesiologists score, body mass index, liver disease, and tumor size. Surgical and postsurgical outcomes were compared.

Results

Seventy-two patients were analyzed: 22 in the LRH group and 50 in the ORH group. Operating time was similar. Blood loss was significantly less in laparoscopic resections (P = .038). Specific morbidity rates were not different, general morbidity was lower after laparoscopy (P = .04), and the severity of postsurgical complications was not different. Mean hospital stay was significantly shorter after laparoscopy (P = .009).

Comments

Laparoscopy improved surgical and postsurgical outcomes for ORH in selected patients. This is the first comparative study to demonstrate an advantage of laparoscopy for a major liver resection. Prospective randomized studies with a greater number of cases are needed to confirm the role of laparoscopy in major liver resections.     

Experiences with the linear cutter technique for performing Roux-en-Y anastomosis following total gastrectomy

The use of stapling devices for performing gastrointestinal anastomosis has recently gained wide acceptance. In fact, since 1991, we have been using linear cutter devices for performing the Roux-en-Y anastomosis, transection of the duodenum, and closure of the jejunal stump (except following esophagojejunostomy), and are no longer employing hand-sewn procedures. In this report, the linear cutter technique used after total gastrectomy is described and the differences in anastomotic leakage, morbidity, operating time, and reconstruction time are evaluated in comparison with those following hand-sewn anastomoses. A total of 22 patients undergoing total gastrectomy within a 2-year period were randomized into two groups of 11, to have reconstruction performed by either a stapled or hand-sewn Roux-en-Y anastomosis. One patient from the stapled group died of acute myocardial infarction 6 days after the operation. Anastomotic leakages from the esophagojejunostomy region occurred in 18% of the patients in the stapled group, but fortunately no leakage was apparent from the Y-anastomosis when the linear cutter technique was used. The most obvious significance was the short mean reconstruction time in the stapled group of 19.1±3.56 min (P<0.01) being 31 min shorter than that of the hand-sewn group (n=11). Thus, we proposed that the linear cutter technique is a safe technique for performing anastomosis following total gastrectomy, which would significantly reduce the reconstruction time.     

陈氏绕肝双悬吊法联合右半肝血流阻断行右后叶肝肿瘤切除术

目的 评价右半肝阻断技术结合陈氏绕肝双悬吊法在右后叶肝肿瘤切除术中的应用价值.方法 2011年1月至2015年1月,在37例解剖性肝脏右后叶切除术中应用持续右半肝及陈氏绕肝双悬吊法辅助肝切除.右后叶肝肿瘤行右后叶切除时,采取持续右半肝阻断技术并结合陈氏绕肝双悬吊法经下腔静脉右侧放置2根提肝带,离断肝实质的过程中通过牵拉提肝带辅助肝切除.结果 全组共37例肝右后叶肿瘤病人行肝右后叶肿瘤切除术.术中均成功分离出右半肝肝蒂和右后叶肝蒂,游离右肝后均成功放置绕肝提拉带,断肝时行右半肝持续肝门阻断,术中无胆管损伤、肝短静脉、肝右静脉撕裂和大出血等相关操作并发症.肝实质离断时间17～28 min,阻断时间约20～30min,术中出血量60～330 ml.术后第1天丙氨酸转氨酶(ALT) 183～352 U/L,生化指标均在1周内恢复正常,无围手术期死亡.结论 右半肝持续阻断结合陈氏绕肝双悬吊法有助于减少右后叶肝切除术中出血量以及改善手术野,缩短肝实质离断时间,减轻肝脏缺血再灌注损伤,其操作简单、使用安全、适用范围广泛.     

The feasibility of combined resection and subsequent reconstruction of the right hepatic artery in left hepatectomy for cholangiocarcinoma

BackgroundCombined resection of the right hepatic artery (RHA) is sometimes required to achieve complete resection of hilar cholangiocarcinoma. The present study aimed to evaluate the feasibility of combined resection and subsequent reconstruction by continuous suture of the RHA during left hepatectomy for cholangiocarcinoma.Materials and methodsWe retrospectively compared the outcomes after left hepatectomy with biliary reconstruction for cholangiocarcinoma between patients with and without RHA resection and reconstruction.ResultsOf the 25 patients who underwent left hepatectomy combined with biliary reconstruction, eight patients (32%) underwent combined resection and reconstruction of the RHA (AR group). The demographic characteristics were not different between the AR and non-AR groups. The amount of intraoperative bleeding was significantly greater in patients with AR (2350 mL vs. 900 mL, p = 0.017). The prevalence of early complications above grade III in Clavien–Dindo classification and late complications were not significantly different between the AR and non-AR groups. In the AR group, complications directly associated with AR, such as thrombosis or reanastomosis, were not observed. On Kaplan–Meier analysis, recurrence-free survival (p = 0.618) and overall survival (p = 0.803) were comparable between the two groups despite the advanced T stages in the AR group.ConclusionsCombined resection and subsequent reconstruction of the RHA during left-sided hepatectomy is a feasible treatment alternative for cholangiocarcinoma.     

腹腔镜辅助活体供者右半肝切取临床应用(附视频)

目的探讨腹腔镜辅助技术在活体肝移植供者右半肝切取中的应用。方法从2011年7月4日至11月1日,四川大学华西医院已完成7例腹腔镜辅助活体肝移植供者右半肝切取(不包括肝中静脉)手术,总结手术方法及其要点。结果 7例供者均未中途转为开放手术。腹腔镜辅助活体供肝切取平均手术时间(6.04±0.36)h,术中平均出血量(150±40)mL。1例供者围手术期出现右侧肋缘下穿刺孔肌肉出血,术后8h予以手术止血成功。余6例供者未发生Clavien-Dindo外科并发症分级二级以上并发症。供者住院费用无明显增加。未观察到腹腔镜辅助手术对移植物的不良影响。结论腹腔镜辅助部分供肝切取明显减少了供者手术创伤,缩短了供者住院时间,值得在活体肝移植供者手术中推广。     

Application of an articulating spacer in two‐stage revision for severe infection after total knee arthroplasty

Objective: To investigate the efficiency and safety of articulating spacer for severe infection after total knee arthroplasty (TKA) in patients with medical comorbidities and local sinus tracts. Methods: Between January 2002 and March 2008, ten consecutive patients with late stage infected TKA complicated by local sinus tracts and medical comorbidities, were treated in our hospital by delayed two‐stage reimplantation using articulating spacers. The modified Hospital for Special Surgery (HSS) knee scoring system was used to evaluate the results. Results: One patient underwent knee fusion as the infection could not be controlled after first‐stage surgery. Infection was eradicated in the other nine patients. The mean follow‐up was 50 months (range, 24–90 months), no recurrent infection developing in these nine patients. The average modified HSS score was 48 points (range, 32–63) before the first‐stage surgery, 79 points (range, 62–91) at the end of the spacer period, and 89 points (range, 74–95) at the latest follow‐up, and the good to excellent rate was 0%, 80% and 100%, respectively. The average range of motion had improved to 8° to 93° at the end of the spacer period, and 3° to 110° at the last follow‐up, compared to 13° to 70° preoperatively. Conclusion: Delayed two‐stage reimplantation using an articulating spacer is effective for treating infected TKA in patients with medical comorbidities or local sinuses.     

直线切割闭合器联合LigaSure在腹腔镜下半肝切除术中的疗效分析

目的:分析直线切割闭合器联合LigaSure在腹腔镜下半肝切除术中的应用价值及临床疗效。方法:回顾分析2014年1月至2015年12月22例行腹腔镜下半肝切除术患者(研究组)的临床资料,术中应用直线切割闭合器联合LigaSure,10例行右半肝切除,12例行左半肝切除;对照组为20例行常规开腹肝癌半肝切除术的患者,11例行左半肝切除。对比两组术中出血量、手术时间、住院时间、术后疼痛评分、住院费用及术后并发症发生率。结果:两组均顺利完成手术,无一例中转开腹。研究组术中出血量[(760.5±409.4)ml]少于对照组[(1 250.5±454.9)ml,P=0.001],手术时间[(235.4±21.4)min]短于对照组[(265.5±20.0)min,P=0.000],住院时间[(4.6±2.2)d]短于对照组[(7.2±3.0)d,P=0.003)],术后疼痛轻于对照组(P=0.031)。两组住院费用差异无统计学意义(P=0.114),术后研究组1例发生肺部感染,对照组1例发生胆漏,两组并发症发生率差异无统计学意义(P=0.919)。结论:腹腔镜半肝切除术中应用直线切割闭合器联合LigaSure具有手术时间短、术中出血量少、术后疼痛轻、康复快的优点,可成为腹腔镜下肝癌半肝切除的首选方法。